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FornnA-&213 r " = r»f
V. S. DEPABTMENT OF T-&ffil_ ., UO * _UC
IMMIGRATION AND NATURALIZATION SKT.VICE
APPLICATION FOR A CERTIFICATE OF ARRIVAL
and
PRELIMINARY FORM FOR A DECLARATION OF INTENTION
No..
For use in searching records of arrival:
RECORDS EXAMINED
Card index
Index books
Manifests
RECORD FOUND
Place _..
Name .
Date.....
Manner.
Use Form 161-Im. in issuing certificate of arrival on
this application.
(Signature of person making search)
TO THE APPLICANT.: Do not write above this line. Read carefully and follow the instructions on last page hereof
Wtif^Take or mail this application and your money order to—
IMMIGRATION AND NATURALIZATION SERVICE. Date _____ „ , 19.
Post Office and Courthouse Building,
LOS ANGELES, CALIF.
£**„
'..., residing at „£_r..Z„T„^
' ^- jp 0 a /7 /) /? (Number and street)
hLy^T?^t^ desire to declare my intention to become a citizen of the United
ityortc^T) 1 (County) V /(State) V . . ■ - ^ J7
States, in accordance with the naturalization law, in th/!&.~^<&^^ Court atih_^..4f*^
(Name of court) (Cityorwwn) (State) ^
I submit herewith a statement of facts to be used in making such declaration, and two photographs of myself, each of which I
have signed.
THIS BLOCK TO BE USED ONLY WHEN ARRIVAL IN THE UNITED STATES WAS AFTER JUNE 29, 1906
I hereby apply for a Certificate of Arrival showing my lawful entry into the United States for permanent residence, required
by law of an alien whose arrival occurred after June 29, 1906, and enclose money order No in the sum of $2.50, made
payable to the order of the "Commissioner of Immigration and Naturalization, Washington, D.C." in payment for the
certificate of my arrival.
I arrived in the United States through the por
under the name of
on the vessel
a$aJ*
rt of AOy^A^A^A2X!AAL^<At,
_ . igityo. town) * (State) U
^jAiA^...(L^AAXL on„..^.^:........^r?. IfOG
(Month)
(Day)"
(Year)
.yXttArt--
(If otherwise than by vessel, show manner of arrival)
I have __^/__^_?!___^__ been absent from the United States since that date, as follows:.
(Give dates of departure and return, ports of entry, and names of vessels)
Additional facts to aid in locating a record^ of my arrival:
1. I have j&OxX&AAzr- used another name in this country. (If so) It was
I used that name because .
2. The full name of the person shown on my steamship tickej;ywas _,,
3. I was born in (fxC^
Q(G*,j or^wn)
on _____-__/_
4. My father's full name is^em*.
5. My mother's maiden name was
6. (If a married woman) My maiden name was .
7. My last foreign residence was -{jfek23=^2r_*---
8. The place where I took the ship or train which lam
><?^n^_^
town)
,n tJafe United States w!
(Month)
ll^iS^^
_lj|^^__.j^
f^^^^^^ * (Country) Iwtol
trWffez- -.-.-Jm*xA^..
\ IGityortown) v (Country)